Primary Care Physicians Can Better Manage the Total Cost of Care for
an Accountable Care Population

October 05, 2016 11:00 AM Eastern Daylight Time

SAN MATEO, Calif.--(EON: Enhanced Online News)--Primary care physicians (“PCPs”) can more effectively manage the total
cost of care when managing the healthcare needs of a covered population. Cave
Consulting Group (“CCGroup”) reached this conclusion after
evaluating the performance of several health plan accountable care and
value-based reimbursement programs.

“For those medical conditions with significant practice
variations, PCPs are involved in treating only 40% of the patient
episodes of care. Examples of medical conditions with significant
practice variations are low back pain, degenerative joint disease,
headaches, derangement of knee, hernias, and ischemic heart disease.”

“On average, PCPs are involved in treating 57% of all prevalent medical
condition episodes of care. This means patients are self-referring to
specialists 43% of the time,” stated Dr.
Douglas G. Cave, President of CCGroup.

He continued, “For those medical conditions with significant practice
variations, PCPs are involved in treating only 40% of the patient
episodes of care. Examples of medical conditions with significant
practice variations are low back pain, degenerative joint disease,
headaches, derangement of knee, hernias, and ischemic heart disease.”

Of the 40% of patient episodes seen by PCPs with significant practice
variations, PCPs referred 35% of these episodes to specialists.
Therefore, PCPs are ‘solely involved’ in treating only about one in four
medical condition episodes with significant practice variations.

“For the 35% of episodes referred to specialists by PCPs, we observe
that only 50% of the specialists are practicing efficiently and
effectively. This finding implies that PCPs may refer to specialists
based on criteria other than efficiency and effectiveness,” defined Dr.
Cave.

Dr. Cave stated, “Under accountable care, PCPs need to become more
active participants in treating medical conditions with significant
practice variations. PCPs need to be informed of the medical conditions
and services with the most practice patterns variation. For these
conditions, PCP involvement needs to be increased from the current 40%
of patient episodes to at least the 90% level. Then, quantitative
clinical pathways should be developed that define the appropriate time
for a specialist referral. When a referral is appropriate, PCPs need to
refer to efficiently and effectively practicing specialists. In this
manner, PCPs can more effectively manage the total cost of care of a
covered population.”

About Cave Consulting Group, Inc. (CCGroup)

Cave Consulting Group, Inc. is a software and consulting firm located in
San Mateo, California. The company is focused on improving the
efficiency (cost-of-care) and effectiveness (quality-of-care) of the
healthcare delivery system. Senior management of CCGroup has assessed
the performance of physicians and hospitals for over 26 years for health
plans, HMOs, physician groups, health systems, TPAs, and employers.